A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

extend one leg and allow the client to slide down the leg to the floor.

move both feet together when the client begins to fall

wrap both arms around the client's arm and shoulders

protect the client's extremities while lowering them to the floor.

Answer and Explanation

The Correct Answer is A

A. Extend one leg and allow the client to slide down the leg to the floor.

It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.

B. Move both feet together when the client begins to fall.

Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.

C. Wrap both arms around the client's arm and shoulders.

This could cause injury to the client’s upper body and doesn't provide support for a safe fall.

D. Protect the client's extremities while lowering them to the floor.

While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.

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Correct Answer is ["B","E"]

Explanation

A. Move overbed tables away from the bed

Overbed tables should be kept within reach so clients don’t overextend or stand unsafely to access them.

B. Instruct the clients to use the call light

Reinforcing use of the call light promotes help-seeking before unsafe mobility attempts.

C. Perform client checks every 4 hr

High-risk clients should be checked more frequently, typically every hour or two, especially overnight.

D. Keep the clients' rooms dark

Poor lighting increases fall risk. A night light should be used.

E. Place a fall risk wristband on each of the clients

Fall risk wristbands alert staff and ensure precautions are taken consistently.

A. reassess the area in 8 hours B. stop the machine and notify the primary care provider C. increase the angle of the flexion of the joint to change the pressure on the heel D. pad the portion of the machine that the heel rests on

Correct Answer is B

Explanation

A. Reassess the area in 8 hours

Delaying action may result in wound dehiscence or further tissue damage.

B. Stop the machine and notify the primary care provider

Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.

C. Increase the angle of the flexion of the joint to change the pressure on the heel

Increasing the angle may worsen the wound separation and increase pressure on the incision.

D. Pad the portion of the machine that the heel rests on

Padding may prevent pressure injury but does not address the wound issue or tightness from movement.

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A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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